Derivation and validation of risk prediction for posttraumatic stress symptoms following trauma exposure.

BACKGROUND: Posttraumatic stress symptoms (PTSS) are common following traumatic stress exposure (TSE). Identification of individuals with PTSS risk in the early aftermath of TSE is important to enable targeted administration of preventive interventions. In this study, we used baseline survey data from two prospective cohort studies to identify the most influential predictors of substantial PTSS. METHODS: Self-identifying black and white American women and men (n = 1546) presenting to one of 16 emergency departments (EDs) within 24 h of motor vehicle collision (MVC) TSE were enrolled. Individuals with substantial PTSS (⩾33, Impact of Events Scale - Revised) 6 months after MVC were identified via follow-up questionnaire. Sociodemographic, pain, general health, event, and psychological/cognitive characteristics were collected in the ED and used in prediction modeling. Ensemble learning methods and Monte Carlo cross-validation were used for feature selection and to determine prediction accuracy. External validation was performed on a hold-out sample (30% of total sample). RESULTS: Twenty-five percent (n = 394) of individuals reported PTSS 6 months following MVC. Regularized linear regression was the top performing learning method. The top 30 factors together showed good reliability in predicting PTSS in the external sample (Area under the curve = 0.79 ± 0.002). Top predictors included acute pain severity, recovery expectations, socioeconomic status, self-reported race, and psychological symptoms. CONCLUSIONS: These analyses add to a growing literature indicating that influential predictors of PTSS can be identified and risk for future PTSS estimated from characteristics easily available/assessable at the time of ED presentation following TSE.

Point-of-care Lung Ultrasound Is More Sensitive than Chest Radiograph for Evaluation of COVID-19.

INTRODUCTION: Current recommendations for diagnostic imaging for moderately to severely ill patients with suspected coronavirus disease 2019 (COVID-19) include chest radiograph (CXR). Our primary objective was to determine whether lung ultrasound (LUS) B-lines, when excluding patients with alternative etiologies for B-lines, are more sensitive for the associated diagnosis of COVID-19 than CXR. METHODS: This was a retrospective cohort study of all patients who presented to a single, academic emergency department in the United States between March 20 and April 6, 2020, and received LUS, CXR, and viral testing for COVID-19 as part of their diagnostic evaluation. The primary objective was to estimate the test characteristics of both LUS B-lines and CXR for the associated diagnosis of COVID-19. Our secondary objective was to evaluate the proportion of patients with COVID-19 that have secondary LUS findings of pleural abnormalities and subpleural consolidations. RESULTS: We identified 43 patients who underwent both LUS and CXR and were tested for COVID-19. Of these, 27/43 (63%) tested positive. LUS was more sensitive (88.9%, 95% confidence interval (CI), 71.1-97.0) for the associated diagnosis of COVID-19 than CXR (51.9%, 95% CI, 34.0-69.3; p = 0.013). LUS and CXR specificity were 56.3% (95% CI, 33.2-76.9) and 75.0% (95% CI, 50.0-90.3), respectively (p = 0.453). Secondary LUS findings of patients with COVID-19 demonstrated 21/27 (77.8%) had pleural abnormalities and 10/27 (37%) had subpleural consolidations. CONCLUSION: Among patients who underwent LUS and CXR, LUS was found to have a higher sensitivity than CXR for the evaluation of COVID-19. This data could have important implications as an aid in the diagnostic evaluation of COVID-19, particularly where viral testing is not available or restricted. If generalizable, future directions would include defining how to incorporate LUS into clinical management and its role in screening lower-risk populations.

Loop Drainage Is Noninferior to Traditional Incision and Drainage of Cutaneous Abscesses in the Emergency Department.

BACKGROUND: There is limited research on loop drainage (LD) compared to incision and drainage (I&D) for treatment of cutaneous abscesses. We investigated whether LD was noninferior to I&D for abscess resolution and whether there was any difference in repeat ED visits or complication rates between these techniques. METHODS: We performed a prospective randomized controlled trial, using a convenience sample at an urban academic emergency department (ED). Subjects over 18 years who presented for first-time management of an abscess were eligible. Patients requiring specialist drainage or hospital admission or had previous treatment for the abscess were excluded. Enrolled subjects were seen 2 weeks after treatment for blinded reevaluation of abscess resolution, and the electronic medical record was reviewed for return ED visits/abscess complications. RESULTS: Of 2,889 patients screened, 238 subjects consented and were randomized to LD or I&D. Abscess resolution was achieved in 53/65 (81.5%) of patients in the I&D arm, compared to 66/75 (88%) in the LD arm. Fewer patients in the LD group compared to the I&D group returned to the ED for abscess-related management during the following 14 days (37.3% vs 67.1%, p = 0.002). Among returning subjects, there was a significant difference in mean visits per subject between LD and I&D groups (0.5 vs. 1.2, p = 0.001). There were fewer complications among LD than I&D subjects (9.3% vs. 24.6%, p = 0.01). CONCLUSION: Our study provides evidence that LD is noninferior to I&D in achieving complete abscess resolution at 14 days and is associated with fewer return ED visits and fewer complications. This makes it an attractive alternative treatment option for abscesses.

Variability in Institutional Board Review for a Multisite Assessment of Resident Professionalism.

Residents serve as both trainees and employees and can be considered potentially vulnerable research participants. This can lead to variation in the institutional review board (IRB) review. We studied sites participating in the Assessment of Professional Behaviors Study sponsored by the National Board of Medical Examiners (2009-2011). Of the 19 sites, all but one were university affiliated. IRB review varied; 2/19 did not submit to a local IRB, 4/17 (23%) were exempt, 11/17 (65%) were expedited, and 2/17 (12%) required full Board review; 12/17 (71%) required written informed consent. The interval from submission to approval was 1 to 2 months (8/17); the range was 1 to 7 months. Although most stated there were no major barriers to approval, the most common concern was resident coercion and loss of confidentiality. Local IRB review of this educational research study varied.

Point-of-care influenza testing does not significantly shorten time to disposition among patients with an influenza-like illness.

INTRODUCTION: Availability of anti-viral agents and need to isolate infected patients increases the need to confirm the diagnosis of influenza before determining patient disposition. OBJECTIVES: We sought to determine if time-to-disposition (TTD) was shorter among patients tested for influenza using an Emergency Department (ED) Point-of-care (POC) test compared to core laboratory (lab) test and to determine difference in antibiotic use between groups. METHODS: We prospectively enrolled a convenience sample of ED patients for whom influenza testing was ordered during influenza season 2017. Participants were randomized to POC or lab. Data collected included demographics, chief complaint, influenza test results, turnaround time (TAT), whether antibiotics were given, and TTD. Descriptive statistics were calculated and group comparisons conducted using chi squared and Wilcoxon Rank Sum tests. RESULTS: Study population included 100 in the POC group and 97 in the lab group. Demographics were similar between POC and lab participants. More flu positive results were reported in the POC group compared to the lab group (51.0% vs. 33.0% p = 0.01). The median TTD was 146.5 min (IQR 98.5) for POC group and 165.5 min (IQR 127) for lab group (p = 0.26). The median TAT was 30.5 min (IQR 7.5) for POC group and 106.0 min (IQR 55) for core lab group (p = 0.001). Antibiotics were given to 14.0% of POC participants and 14.4% of lab participants (p = 0.93). CONCLUSIONS: Although use of a POC influenza test provided more rapid TAT than use of a core lab test, there was no significant difference in TTD or antibiotic use between groups.

The Intersection of Gender and Resuscitation Leadership Experience in Emergency Medicine Residents: A Qualitative Study.

OBJECTIVES: The objective was to examine emergency medicine (EM) residents' perceptions of gender as it intersects with resuscitation team dynamics and the experience of acquiring resuscitation leadership skills. METHODS: This was an exploratory, qualitative study using grounded theory and a purposive sample of postgraduate year (PGY) 2-4 EM residents who function as resuscitation team leaders in two urban EM programs. One-on-one interviews were conducted by a single experienced researcher. Audiotaped interviews were transcribed and deidentified by two research assistants. A research team composed of a PhD educational researcher, a research nurse, an MPH research assistant, and an EM resident reviewed the transcripts and coded and analyzed data using MAXQDA v12. Themes and coding schema were discussed until consensus was reached. We used member checking to assess the accuracy of our report and to confirm that the interpretations were fair and representative. RESULTS: Theme saturation was reached after interviewing 16 participants: 10 males and 6 females. The three major themes related to gender that emerged included leadership style, gender inequality, and relationship building. Both male and female residents reported that a directive style was more effective when functioning in the resuscitation leadership role. Female residents more often expressed discomfort with a directive style of leadership, preferring a more communicative and collaborative style. Both female and male residents identified several challenges as disproportionately affecting female residents, including negotiating interactions with nurses more and "earning the respect" of the team members. CONCLUSIONS: Residents acknowledged that additional challenges exist for female residents in becoming resuscitation team leaders. Increasing awareness in residency program leadership is key to affecting change to ensure all residents are trained in a similar manner, while also addressing gender-specific needs of residents where appropriate. We present suggestions for addressing these barriers and incorporating discussion of leadership styles into residency training.

Is hallway care dangerous? An observational study.

OBJECTIVES: In response to crowding the use of hallway beds has become an increasingly prevalent practice in Emergency Departments (EDs). There is limited research on whether caring for patients in hallways (HP) is associated with adverse outcomes. The goal of this study was to examine the effects of HP triage on 30 day outcomes for ED return, readmission, and mortality. METHODS: We performed a retrospective cohort study at an urban, academic ED comparing HPs (defined as HP for ≥30 min) to matched controls triaged to standard ED beds from 9/30/14 to 10/1/15. We analyzed data from the hospital's clinical data warehouse. Matched controls were selected by gender, age, ethnicity, and language. We used McNemar's test to assess the association between triage location and 30 day study outcomes. We also examined adverse outcomes by triage severity using McNemar's test. RESULTS: A total of 10,608 HPs were matched to control patients. Compared to controls, HPs had 2.0 times the odds of returning to the ED in 30 days (95% CI: 1.8-2.1), 1.6 times the odds of inpatient readmission (95% CI: 1.4-1.9), and 1.7 times the odds of readmission to observation (95% CI: 1.4-2.0). The odds ratio for mortality in HPs versus controls was 0.80, (95% CI: 0.50-1.3). CONCLUSIONS: Patients initially triaged to the hallway have an increased odds of 30 day return to the ED, observation and inpatient admission. After adjusting for ESI, the increased odds for return remained similar. The small sample size precluded testing effects of HP status on mortality.

Fantastic Learning Moments and Where to Find Them.

INTRODUCTION: Experiential learning is crucial for the development of all learners. Literature exploring how and where experiential learning happens in the modern clinical learning environment is sparse. We created a novel, web-based educational tool called "Learning Moment" (LM) to foster experiential learning among our learners. We used data captured by LM as a research database to determine where learning experiences were occuring within our emergency department (ED). We hypothesized that these moments would occur more frequently at the physician workstations as opposed to the bedside. METHODS: We implemented LM at a single ED's medical student clerkship. The platform captured demographic data including the student's intended specialty and year of training as well as "learning moments," defined as logs of learner self-selected learning experiences that included the clinical "pearl," clinical scenario, and location where the "learning moment" occurred. We presented data using descriptive statistics with frequencies and percentages. Locations of learning experiences were stratified by specialty and training level. RESULTS: A total of 323 "learning moments" were logged by 42 registered medical students (29 fourth-year medical students (MS 4) and 13 MS 3 over a six-month period. Over half (52.4%) intended to enter the field of emergency medicine (EM). Of these "learning moments," 266 included optional location data. The most frequently reported location was patient rooms (135 "learning moments", 50.8%). Physician workstations hosted the second most frequent "learning moments" (67, 25.2%). EM-bound students reported 43.7% of "learning moments" happening in patient rooms, followed by workstations (32.8%). On the other hand, non EM-bound students reported that 66.3% of "learning moments" occurred in patient rooms and only 8.4% at workstations (p<0.001). CONCLUSION: LM was implemented within our ED as an innovative, web-based tool to fulfill and optimize the experiential learning cycle for our learners. In our environment, patient rooms represented the most frequent location of "learning moments," followed by physician workstations. EM-bound students were considerably more likely to document "learning moments" occurring at the workstation and less likely in patient rooms than their non EM-bound colleagues.

Are Geriatric Patients Placed in an Emergency Department Observation Unit on a Chest Pain Pathway More Likely Than Non-Geriatric Patients to Re-Present to the Hospital within 30 Days?

BACKGROUND: Emergency department observation units (EDOUs) are used frequently for low-risk chest pain evaluations. OBJECTIVE: The purpose of this study was to determine whether geriatric compared to non-geriatric patients evaluated in an EDOU for chest pain have differences in unscheduled 30-day re-presentation, length of stay (LOS), and use of stress testing. METHODS: We conducted an exploratory, retrospective, cohort study at a single academic, urban ED of all adult patients placed in an EDOU chest pain protocol from June 1, 2014 to May 31, 2015. Our primary outcome was any unscheduled return visits within 30 days of discharge from the EDOU. Secondary outcomes included EDOU LOS and stress testing. We used Wilcoxon non-parametric and χ2 tests to compare geriatric to non-geriatric patients. RESULTS: There were 959 unique EDOU placements of geriatric (n = 219) and non-geriatric (n = 740) patients. Geriatric compared to non-geriatric patients had: no significant difference in unscheduled 30-day return visits after discharge from the EDOU (15.5% vs. 18.5%; p = 0.31); significantly longer median EDOU LOS (22.1 vs. 20.6 h; p < 0.01) with a greater percentage staying longer than 24 h (42% vs. 29.1%; p < 0.01). Geriatric patients had significantly fewer stress tests (39.7% vs. 51.4%; p < 0.01), more of which were nuclear stress tests (78.2% vs. 39.5%; p < 0.01). CONCLUSIONS: In this exploratory retrospective study, geriatric EDOU chest pain patients did not have an increased rate of re-presentation to the hospital within 30 days compared to non-geriatric patients. Geriatric patients had a longer EDOU LOS than non-geriatric patients. Geriatric patients in the EDOU had fewer stress tests, but more of those were nuclear stress tests.

Is the Pelvic Examination Still Crucial in Patients Presenting to the Emergency Department With Vaginal Bleeding or Abdominal Pain When an Intrauterine Pregnancy Is Identified on Ultrasonography? A Randomized Controlled Trial.

STUDY OBJECTIVE: We determine whether omitting the pelvic examination in emergency department (ED) evaluation of vaginal bleeding or lower abdominal pain in ultrasonographically confirmed early intrauterine pregnancy is equivalent to performing the examination. METHODS: We conducted a prospective, open-label, randomized, equivalence trial in pregnant patients presenting to the ED from February 2011 to November 2015. Patients were randomized to no pelvic examination versus pelvic examination. Inclusion criteria were aged 18 years or older, English speaking, vaginal bleeding or lower abdominal pain, positive ß-human chorionic gonadotropin result, and less than 16-week intrauterine pregnancy by ultrasonography. Thirty-day record review and follow-up call assessed for composite morbidity endpoints (unscheduled return, subsequent admission, emergency procedure, transfusion, infection, and alternate source of symptoms). Wilcoxon rank sum tests were used to assess patient satisfaction and throughput times. RESULTS: Only 202 (of a planned 720) patients were enrolled, despite extension of the study enrollment period. The composite morbidity outcome was experienced at similar rates in the intervention (no pelvic examination) and control (pelvic examination) groups (19.6% versus 22.0%; difference -2.4%; 90% confidence interval [CI] -11.8% to 7.1%). Patients in the intervention group were less likely to report feeling uncomfortable or very uncomfortable during the visit (11.2% versus 23.7%; difference -12.5; 95% CI -23.0% to -2.0%). CONCLUSION: Although there was only a small difference between the percentage of patients experiencing the composite morbidity endpoint in the 2 study groups (2.4%), the resulting 90% CI was too wide to conclude equivalence. This may have been due to insufficient power. Patients assigned to the pelvic examination group reported feeling uncomfortable more frequently.

Use of Intranasal Naloxone by Basic Life Support Providers.

STUDY OBJECTIVES: Intranasal delivery of naloxone to reverse the effects of opioid overdose by Advanced Life Support (ALS) providers has been studied in several prehospital settings. In 2006, in response to the increase in opioid-related overdoses, a special waiver from the state allowed administration of intranasal naloxone by Basic Life Support (BLS) providers in our city. This study aimed to determine: 1) if patients who received a 2-mg dose of nasal naloxone administered by BLS required repeat dosing while in the emergency department (ED), and 2) the disposition of these patients. METHODS: This was a retrospective review of patients transported by an inner-city municipal ambulance service to one of three academic medical centers. We included patients aged 18 and older that were transported by ambulance between 1/1/2006 and 12/12/2012 and who received intranasal naloxone by BLS providers as per a state approved protocol. Site investigators matched EMS run data to patients from each hospital's EMR and performed a chart review to confirm that the patient was correctly identified and to record the outcomes of interest. Descriptive statistics were then generated. RESULTS: A total of 793 patients received nasal naloxone by BLS and were transported to three hospitals. ALS intervened and transported 116 (14.6%) patients, and 11 (1.4%) were intubated in the field. There were 724 (91.3%) patients successfully matched to an ED chart. Hospital A received 336 (46.4%) patients, Hospital B received 210 (29.0%) patients, and Hospital C received 178 (24.6%) patients. Mean age was 36.2 (SD 10.5) years and 522 (72.1%) were male; 702 (97.1%) were reported to have abused heroin while 21 (2.9%) used other opioids. Nasal naloxone had an effect per the prehospital record in 689 (95.2%) patients. An additional naloxone dose was given in the ED to 64 (8.8%) patients. ED dispositions were: 507 (70.0%) discharged, 105 (14.5%) admitted, and 112 (15.5%) other (e.g., left against medical advice, left without being seen, or transferred). CONCLUSIONS: Only a small percentage of patients receiving prehospital administration of nasal naloxone by BLS providers required additional doses of naloxone in the ED and the majority of patients were discharged.

Why is it so hard to implement change? A qualitative examination of barriers and facilitators to distribution of naloxone for overdose prevention in a safety net environment.

BACKGROUND: The increase in opioid overdose deaths has become a national public health crisis. Naloxone is an important tool in opioid overdose prevention. Distribution of nasal naloxone has been found to be a feasible, and effective intervention in community settings and may have potential high applicability in the emergency department, which is often the initial point of care for persons at high risk of overdose. One safety net hospital introduced an innovative policy to offer take-home nasal naloxone via a standing order to ensure distribution to patients at risk for overdose. The aims of this study were to examine acceptance and uptake of the policy and assess facilitators and barriers to implementation. METHODS: After obtaining pre-post data on naloxone distribution, we conducted a qualitative study. The PARiHS framework steered development of the qualitative guide. We used theoretical sampling in order to include the range of types of emergency department staff (50 total). The constant comparative method was initially used to code the transcripts and identify themes; the themes that emerged from the coding were then mapped back to the evidence, context and facilitation constructs of the PARiHS framework. RESULTS: Acceptance of the policy was good but uptake was low. Primary themes related to facilitators included: real-world driven intervention with philosophical, clinician and leadership support; basic education and training efforts; availability of resources; and ability to leave the ED with the naloxone kit in hand. Barriers fell into five general categories: protocol and policy; workflow and logistical; patient-related; staff roles and responsibilities; and education and training. CONCLUSIONS: The actual implementation of a new innovation in healthcare delivery is largely driven by factors beyond acceptance. Despite support and resources, implementation was challenging, with low uptake. While the potential of this innovation is unknown, understanding the experience is important to improve uptake in this setting and offer possible solutions for other facilities to address the opioid overdose crisis. Use of the PARiHS framework allowed us to recognize and understand key evidence, contextual and facilitation barriers to the successful implementation of the policy and to identify areas for improvement.

A critical analysis of unplanned ICU transfer within 48 hours from ED admission as a quality measure.

HYPOTHESIS: Unplanned intensive care unit (ICU) transfer (UIT) within 48 hours of emergency department (ED) admission increases morbidity and mortality. We hypothesized that a majority of UITs do not have critical interventions (CrIs) and that CrI is associated with worse outcomes. OBJECTIVE: The objective of the study is to characterize all UITs (including patients who died before ICU transfer), the proportion with CrI, and the effect of having CrI on mortality. DESIGN: This is a single-center, retrospective cohort study of UITs within 48 hours from 2008 to 2013 at an urban academic medical center and included patients 18 years or older without advanced directives (ADs). Critical intervention was defined by modified Delphi process. Data included demographics, comorbidities, reasons for UIT, length of stay, CrIs, and mortality. We calculated descriptive statistics with 95% confidence intervals (CIs). RESULTS: A total of 837 (0.76%) of 108 732 floor admissions from the ED had a UIT within 48 hours; 86 admitted patients died before ICU. We excluded 23 ADs, 117 postoperative transfers, 177 planned ICU transfers, and 4 with missing data. Of the 516 remaining, 65% (95% CI, 61%-69%) received a CrI. Unplanned ICU transfer reasons are as follows: 33 medical errors, 90 disease processes not present on arrival, and 393 clinical deteriorations. Mortality was 10.5% (95% CI, 8%-14%), and mean length of stay was 258 hours (95% CI, 233-283) for those with CrI, whereas the mortality was 2.8% (95% CI, 1%-6%) and mean length of stay was 177 hours (95% CI, 157-197) for those without CrI. CONCLUSIONS: Unplanned ICU transfer is rare, and only 65% had a CrI. Those with CrI had increased morbidity and mortality.

Academic Emergency Medicine Physicians' Knowledge of Mechanical Ventilation.

INTRODUCTION: Although emergency physicians frequently intubate patients, management of mechanical ventilation has not been emphasized in emergency medicine (EM) education or clinical practice. The objective of this study was to quantify EM attendings' education, experience, and knowledge regarding mechanical ventilation in the emergency department. METHODS: We developed a survey of academic EM attendings' educational experiences with ventilators and a knowledge assessment tool with nine clinical questions. EM attendings at key teaching hospitals for seven EM residency training programs in the northeastern United States were invited to participate in this survey study. We performed correlation and regression analyses to evaluate the relationship between attendings' scores on the assessment instrument and their training, education, and comfort with ventilation. RESULTS: Of 394 EM attendings surveyed, 211 responded (53.6%). Of respondents, 74.5% reported receiving three or fewer hours of ventilation-related education from EM sources over the past year and 98 (46%) reported receiving between 0-1 hour of education. The overall correct response rate for the assessment tool was 73.4%, with a standard deviation of 19.9. The factors associated with a higher score were completion of an EM residency, prior emphasis on mechanical ventilation during one's own residency, working in a setting where an emergency physician bears primary responsibility for ventilator management, and level of comfort with managing ventilated patients. Physicians' comfort was associated with the frequency of ventilator changes and EM management of ventilation, as well as hours of education. CONCLUSION: EM attendings report caring for mechanically ventilated patients frequently, but most receive fewer than three educational hours a year on mechanical ventilation, and nearly half receive 0-1 hour. Physicians' performance on an assessment tool for mechanical ventilation is most strongly correlated with their self-reported comfort with mechanical ventilation.

Characteristics of state prescription drug monitoring programs: a state-by-state survey.

OBJECTIVES: Prescription drug monitoring programs (PDMPs) are state-based data collection systems recording controlled substance medications. Currently, 49 states have PDMPs. There are discrepancies in reporting patterns, infrastructure, and oversight between programs. We characterized aspects of each state's PDMP. METHODS: A web search of each state's PDMP was conducted, and a list of all PDMP administrators was obtained. From August 1 to November 31, 2014, a link to a web-based survey was sent to each PDMP administrator. Closed-ended questions included type of access, mandatory-use programs, data sharing, proactive contact with patients or health care providers, details of pharmacy reporting, and protocols for identifying "high-risk" patients. Descriptive statistics were used for analysis. RESULTS: We received a 100% response rate (49/49). Ninety-six percent (47/49) have a physician-accessible PDMP. Most, 68% (32/49), do not have an enrollment mandate for physicians. Prior to prescribing controlled medications, 16% (8/49) require prescribers to access their state's PDMP. More than half of states (53%, 26/49) reported patient prescriptions over the past two or more years. Most, 57% (28/59), reported a lag time of 1 week or longer for patients to appear in a PDMP database after prescription filling. A majority of states (65% 32/49) share data with at least one other state. Protocols exist to identify high-risk patients for prescription drug misuse in 55% (27/49) of states. CONCLUSION: Characteristics of PDMPs are heterogeneous throughout the country. Standardizing data capture, availability, and reporting would improve their usefulness for providers. Copyright © 2016 John Wiley & Sons, Ltd.

Identifying Patients for Overdose Prevention With ICD-9 Classification in the Emergency Department, Massachusetts, 2013-2014.

The national rise in opioid overdose deaths signifies a need to integrate overdose prevention within healthcare delivery settings. The emergency department (ED) is an opportune location for such interventions. To effectively integrate prevention services, the target population must be clearly defined. We used ICD-9 discharge codes to establish and apply overdose risk categories to ED patients seen from January 1, 2013 to December 31, 2014 at an urban safety-net hospital in Massachusetts with the goal of informing ED-based naloxone rescue kit distribution programs. Of 96,419 patients, 4,468 (4.6%) were at increased risk of opioid overdose, defined by prior opioid overdose, misuse, or polysubstance misuse. A small proportion of those at risk were prescribed opioids on a separate occasion. Use of risk categories defined by ICD-9 codes identified a notable proportion of ED patients at risk for overdose, and provides a systematic means to prioritize and direct clinical overdose prevention efforts.

Interactive Learning Module Improves Resident Knowledge of Risks of Ionizing Radiation Exposure From Medical Imaging.

Physician awareness of the risks of ionizing radiation exposure related to medical imaging is poor. Effective educational interventions informing physicians of such risk, especially in emergency medicine (EM), are lacking. The SIEVERT (Suboptimal Ionizing Radiation Exposure Education - A Void in Emergency Medicine Residency Training) learning module was designed to improve provider knowledge of the risks of radiation exposure from medical imaging and comfort in communicating these risks to patients. The 1-hour module consists of introductory lecture, interactive discussion, and role-playing scenarios. In this pilot study, we assessed the educational effect using unmatched, anonymous preintervention and postintervention questionnaires that assessed fund of knowledge, participant self-reported imaging ordering practices in several clinical scenarios, and trainee comfort level in discussing radiation risks with patients. All 25 EM resident participants completed the preintervention questionnaire, and 22 completed the postintervention questionnaire within 4 hours after participation. Correct responses on the 14-question learning assessment increased from 6.32 (standard deviation = 2.36) preintervention to 12.23 (standard deviation = 1.85) post-intervention. Overall, 24% of residents were comfortable with discussing the risks of ionizing radiation exposure with patients preintervention, whereas 41% felt comfortable postintervention. Participants ordered fewer computed tomography scans in 2 of the 4 clinical scenarios after attending the educational intervention. There was improvement in EM residents' knowledge regarding the risks of ionizing radiation exposure from medical imaging, and increased participant self-reported comfort levels in the discussion of these risks with patients after the 1-hour SIEVERT learning module.

Treatment of Cases of Neisseria gonorrhoeae and Chlamydia trachomatis in Emergency Department Patients.

BACKGROUND: The aim of this study was to determine the proportion of patients treated appropriately, both presumptively in the emergency department (ED), and at follow-up, among those patients who ultimately tested positive for either Neisseria gonorrhoeae (NG) or Chlamydia trachomatis (CT). Secondary aims were to characterize patients who received appropriate presumptive antibiotic treatment of both NG and CT at the time of ED visit and to compare them to patients who did not receive appropriate presumptive therapy. METHODS: A retrospective chart review was performed on 500 patients randomly chosen from those that had positive NG or CT test results performed in the ED between January 10 and June 11. The Center for Disease Control and Prevention 2010 STD Treatment Guidelines were used to determine appropriate antibiotics. RESULTS: We found 54% (95% confidence interval [CI], 49%-58%) of patients received appropriate antibiotics at ED visit and an additional 31% (95% CI, 27%-35%) were treated at our medical center on follow-up. Fifteen percent did not have documented treatment. Providers presumptively treated 46% (95% CI, 42%-50%) of patients studied with antibiotics appropriate for both NG and CT. The presence of behavioral risk factors and, for males, the presence of genital symptoms were the only factors independently associated with presumptive ED treatment. CONCLUSIONS: Among patients diagnosed as having NG or CT in this ED, a portion were not documented to ever receive appropriate antibiotics, although a call-back system is in place. Presumptive treatment was not commonly used in this ED but may be necessary given the high number of patients who never got treated.

Opioid education and nasal naloxone rescue kits in the emergency department.

INTRODUCTION: Emergency departments (EDs) may be high-yield venues to address opioid deaths with education on both overdose prevention and appropriate actions in a witnessed overdose. In addition, the ED has the potential to equip patients with nasal naloxone kits as part of this effort. We evaluated the feasibility of an ED-based overdose prevention program and described the overdose risk knowledge, opioid use, overdoses, and overdose responses among participants who received overdose education and naloxone rescue kits (OEN) and participants who received overdose education only (OE). METHODS: Program participants were surveyed by telephone after their ED visit about their substance use, overdose risk knowledge, history of witnessed and personal overdoses, and actions in a witnessed overdose including use of naloxone. RESULTS: A total of 415 ED patients received OE or OEN between January 1, 2011 and February 28, 2012. Among those, 51 (12%) completed the survey; 37 (73%) of those received a naloxone kit, and 14 (27%) received OE only. Past 30-day opioid use was reported by 35% OEN and 36% OE, and an overdose was reported by 19% OEN and 29% OE. Among 53% (27/51) of participants who witnessed another individual experiencing an overdose, 95% OEN and 88% OE stayed with victim, 74% OEN and 38% OE called 911, 26% OEN and 25% OE performed rescue breathing, and 32% OEN (n=6) used a naloxone kit to reverse the overdose. We did not detect statistically significant differences between OEN and OE-only groups in opioid use, overdose or response to a witnessed overdose. CONCLUSION: This is the first study to demonstrate the feasibility of ED-based opioid overdose prevention education and naloxone distribution to trained laypersons, patients and their social network. The program reached a high-risk population that commonly witnessed overdoses and that called for help and used naloxone, when available, to rescue people. While the study was retrospective with a low response rate, it provides preliminary data for larger, prospective studies of ED-based overdose prevention programs.

Characteristics of emergency department "doctor shoppers".

BACKGROUND: There is a need to accurately identify patients at risk for drug abuse before giving a prescription for a scheduled medication. OBJECTIVE: Our aim was to describe a subset of emergency department (ED) patients that had eight or more schedule II-V prescriptions filled from eight or more providers in 1 year, known as "doctor-shopping" (DS) behavior, to compare demographic features of DS and non-DS patients, and to determine clinical factors associated with DS. METHODS: We conducted a prospective, observational study of emergency providers' (EPs) assessment of patients with back pain, dental pain, or headache. EPs recorded patient demographics, clinical characteristics, and numbers of schedule II-V prescriptions, subset opioid prescriptions, providers, and pharmacies utilized in a 12-month period, as reported on the state prescription drug-monitoring program. χ(2) and t-tests were used to compare DS with non-DS patients on demographics; a multivariate logistic regression was performed to determine clinical factors associated with DS. RESULTS: Five hundred and forty-four patient visits were recorded; 12.3% (n = 67) had DS behavior. DS and non-DS patients were similar in sex but differed in age, race, chief complaint, and weekday vs. weekend arrival. DS patients utilized a median of 12.0 (interquartile range [IQR] 9.0-18.0) providers compared with a median of 1.0 (IQR 0-2.0) providers in the non-DS group. Reporting allergies to non-narcotic medications (odds ratio [OR] = 3.1; 95% confidence interval [CI] 1.4-6.9; p = 0.01), requesting medications by name (OR = 2.7; 95% CI 1.5-4.9; p < 0.01), and hospital site (OR = 2.0; 95% CI 1.1-3.6; p = 0.03) were significantly associated with DS. CONCLUSIONS: There are multiple clinical characteristics associated with DS in this patient population.